Sunday, March 31, 2013

Man Up and Check'em

Testicular cancer is the #1 cancer among men ages 15-35.

Caught early, testicular cancer has a cure rate of 99%, usually just with removal of the affected testicle. The good news is even if the cancer has spread the cure rate is still quite good but will entail radiation and chemotherapy. The bad news is each year 360 men will die in the United States from testicular cancer.

Testicular cancer is among the fastest moving cancers so early detection makes a real difference. The best way to catch it is with a monthly self-examination while showering. If you notice something, check with your doctor right away. Studies have shown that men wait two months – critical time.

Self-examination is easy and takes about 45 seconds once a month. For a free shower card, go to There are also tips for parents who don’t know how to start an awkward conversation.

Man up and check ‘em.

Monday, March 18, 2013

Is There a Transplant in Your Future?

Nonalcoholic steatohepatitis (NASH) is the second most common U.S. indication for liver transplantation, trailing only hepatitis C.  We expect to see a fall-off in hepatitis C in the future but the transplant surgeons will still be busy: patients with NASH are going to replace them.

There is substantial evidence linking NASH to obesity, diabetes and the metabolic syndrome. Non-alcoholic fatty liver disease (human foie gras) progresses to NASH in 40% of patients. NASH occurs when the liver cells are damaged by sludge inside the cells and stop working correctly. These cells then die and are replaced with scar tissue. Liver cirrhosis is an accumulation of scar tissue that can lead to organ failure or liver cancer. While the liver has an amazing capacity to regenerate, these scar areas cannot do so.

The metabolic syndrome is rampant: abdominal obesity, high blood pressure, diabetes and elevated cholesterol. Check out the lunchtime crowd at a local fast food emporium – there will be at least one person there who will need a liver transplant in the future, if he doesn’t succumb to heart disease first.

Several experts are recommending that morbidly obese patients who have poorly controlled diabetes have routine screening for liver cancer, since these patients may skip the ‘intermediate step’ of developing cirrhosis. But how to screen? And will it change outcomes?

It is clear that life-style modifications are important. A 7-10% weight loss results in a 50% drop in liver fat. The role of medication in preventing NASH is less clear. In addition to diet and exercise, medications should be used to manage the hypertension, diabetes and high cholesterol that encompass the metabolic syndrome.

The total cost of a liver transplant is more than $500,000 for the first year. Perhaps we should have warning labels on fast food wrappers. 

Tuesday, March 12, 2013

Too Much Testing

Patients who receive diagnostic tests for the purpose of reassurance don’t feel less worried in either the short or long terms, according to a very large analysis of fourteen clinical trials.

When the physician believes that the probability of a disease is low, there is no additional benefit in running the tests “just to be sure.” The reassurance of a negative tests offers comfort that can last as little as a few hours – “a fleeting sense of relief” – instead of long-term assurance. Ordering more tests is not the best response to the worried well.

Testing is sometimes offered in an attempt to wrap up a problem in just one visit, responding to patients concerns about increasing office co-pays and larger deductibles. This is false economy: the analysis shows that it requires testing 16-26 patients to avoid one repeat visit, and the tests cost $250 to $500 per test, therefore the health care system is spending between $4000 and $16,000 to prevent a $100 primary care visit.

There are currently evidence-based guidelines for testing for common conditions. More testing is not better medicine. Now – if only malpractice lawyers would get on board ….

Friday, March 8, 2013

Too Much Caffeine

One third to one half of all teens and young adults consume energy drinks regularly and nearly one half of deployed military personnel report daily use. These drinks are loaded with caffeine. A single cup of coffee has 100 mg of caffeine; this results in a blood level of 1-2 mcg/mL. The usual caffeine content of an energy drink is 80 to 140 mg but some have double that level. A potentially level dose of 3000 mg caffeine (80 mcg/mL blood level) can be reached by consumption of 12 highly caffeinated drinks within a few hours.

There are many ingredients in energy drinks and reading the label might not reveal the entire story. Guarana, also known as Brazilian cocoa, is a South American plant that contains the caffeine compound guaranine. One gram of guaranine is equal to 40 mg of caffeine, but it’s typically not included in the total caffeine count.  It’s like having caffeine with caffeine.

These drinks are particularly dangerous when combined with alcohol. The combination is believed to lessen the effects of alcohol but actually lessens the perception of impairment and encourages greater alcohol consumption. The combination of alcohol and energy drinks is associated with an increase of risk of riding with or being an intoxicated driver as well as the risk of committing or experiencing sexual assault. These drinks are marketed as dietary supplements and are exempt from most regulations.  Many states have banned the sale of premixed alcohol/energy drinks.

A reasonable goal for adults is a maximum of 500 mg of caffeine daily. This is only 30 ounces of coffee – a Starbucks Vente is 20 ounces, a Dunkin Donuts medium hot coffee has 14 ounces but the large iced coffee has 30 ounces. Children and adolescents have no need for any caffeine at all.

Sunday, March 3, 2013

Saving Primary Care

The people who make health care policy are not too worried about getting into to see a doctor. They have insurance and know a lot of physicians or know people who know a lot of physicians who can make a telephone call. Not everyone has that access.

With the onset of the Affordable Care Act, many more people will have some kind of medical insurance. However, they might not have access to a doctor. The United States has too few primary physicians. There are many reasons for this, but like many problems this can be solved with money. Alan Sager, PhD, of Boston University School of Health has a proposal to make primary care more attractive for doctors: raise their incomes to match those of subspecialists. According to Dr. Sager, diverting 3% of healthcare spending to primary care would allow more parity in income. (Other countries spend 10% on primary care.)

This is very different than loan forgiveness, another proposal for enticing medical students to enter primary care. If a person owes $200,000 of medical school debt, that is only a one year salary differential between a general internist and an interventional radiologist.

An increasing number of primary care doctors are not accepting Medicare patients – funding is at the pleasure of the Congress. Private insurance company payments are highly prejudicial against primary care physicians even as the doctors are expected to (in addition to taking care of their patients) coordinate care, ensure continuity and appropriateness of care and hold down costs.

Primary care doctors are desperately treading water – and may soon be drowning. It doesn’t matter how many doctors one knows: the phone will not be answered.